The Art of Medicine

In The Art of Medicine, Toronto Western Hospital’s legendary internist Dr. Herbert Ho Ping Kong draws on his vast dossier of personal cases and five decades as a clinician, to examine the core principles of a patient-centred approach to diagnosis and treatment. While HPK, as he is fondly known, recognizes and applauds the many invaluable innovations in medical technology, as disease and its management grow increasingly complex, he insists that physicians must learn to develop an arsenal of more basic skills, actively using the arts of seeing, hearing, palpation, empathy, and advocacy to provide a more humane and holistic form of care. Aimed at medical practitioners, trainees, aspiring doctors and laymen, the book also contains interviews with more than a dozen of HPK’s patients, as well as short essays that explore the thinking of some 15 of his professional colleagues on the art of medicine.

It is more important to know what sort of person has a ­disease than to know what sort of disease a person has.

— Hippocrates

METAPHORICALLY, THE ART OF MEDICINE is a clinic that contains many rooms. In each, a different art is demonstrated.

In one room, there is the art of seeing, diagnosing illness by carefully observing what may be hiding in plain sight.

In a second, there is the art of listening, actively tuning in to the signature rhythms of the patient’s body, hearing both what the patient says and, equally important, what he or she may not be saying.

In a third, there is the art of human touch, which includes not only feeling the pulse, palpating the spleen, the kidneys and other organs to make the diagnosis, but may also include simply holding the patient’s hand to let them know that you care.

Two other rooms are dedicated to what is often called the Grey Zone. One is for patients who exhibit a range of clinical symptoms that defy simple diagnosis. They are clearly suffering, but there is no agreed-upon name for their ailment. How does the sensitive clinician deal with that increasingly common situation?

The whole art of medicine is in observation … but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that you can do.

— Sir William Osler

I ALWAYS KNEW THAT I WOULD become a doctor.

I knew it not, as one might expect, because my parents coaxed me toward the profession, but because of my childhood nanny. Let me explain.

I was the third child born — in 1939 — into a family of 10 in Summerfield, a country town in the district of Clarendon, some distance from the Jamaican capital of Kingston. My parents were both Hakka Chinese, a minority that, through the centuries, has exerted enormous influence in China’s political and social history.

My grandfather had arrived a generation earlier from China to work in the Caribbean cane sugar fields as an indentured labourer — one unglorified step up from slave. In time, some 10,000 Chinese would settle in Jamaica and, through thrift and hard work, become prosperous, particularly in the retail trade. So prosperous, in fact, that by the mid-1960s, racial tensions with the indigenous Jamaican community were bubbling up.

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.

— Sir William Osler

THE HARD DECISION TO EMIGRATE having been made, I now faced another thorny question: where exactly to go. A number of friends and colleagues had happily moved to the United States, and I did receive a few informal American overtures. But my first preference was Canada, which I judged to be a gentler society.

Accordingly, I sent letters of introduction to the chiefs of medicine at hospitals in several major Canadian cities. General internists were not in high demand at the time, so I was not exactly deluged with offers. But I did receive replies about potential positions in Halifax, Edmonton and St. John’s. I made a visit to Ottawa, but was discouraged by the February snowbanks that literally reached to the eaves of houses. And one Toronto physician-in-chief expressed interest, but with a caveat: he wanted me to effectively audition in private practice for a few years before applying for a staff position.

Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first.

— Sir William Osler

WHEN WE FIRST ARRIVED IN MONTREAL, my wife and I initially planned to stay for three years, and then assess our professional situation. As it happened, our third anniversary in 1976 roughly coincided with the surprise election of the separatist Parti Québécois, led by the mercurial journalist-turned-politician René Lévesque.

The election results sent the anglophone community in Quebec into a state of shock. I vividly recall walking into Royal Victoria Hospital, at the north end of the McGill University campus, at 9 a.m. on the morning after the election and finding it virtually deserted. The corridors, coffee shops — completely empty. It was as if an official order had been issued to vacate the entire premises.

SEVERAL YEARS AGO, A CHINESE-CANADIAN named Charles developed a nagging pain in his back. He was about 56 years old and, though he had prospered since he’d immigrated, and managed to save enough funds to own a building, he continued to work as a labourer, loading boxes of vegetables on and off delivery trucks. He continued to work through the pain for about a month but, eventually, it grew so severe that he had to stop. Through his employer, Charles consulted an orthopedic specialist retained by the Workers’ Compensation Board. The doctor diagnosed osteoarthritis and prescribed painkillers.

But by then, Charles had also started to lose weight. He was sent for a series of tests, which indicated the presence of red blood cells in his urine. That finding raised the possibility of kidney disease, so he was sent to a nephrologist who did further tests, confirming that Charles’s urine contained blood, and suggested that he might have IgA (immunoglobulin A) nephropathy, a common kidney disease that affects the organ’s filters, or glomeruli. Although the condition is mostly benign, the kidney may, over time, lose its ability to cleanse the blood properly.

Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.

— Paracelsus

ALTHOUGH IT MIGHT BE CONSIDERED a relatively minor aspect of the clinical examination, the art of palpation — using human touch to assess the patient — is, in fact, one of the most useful skills a physician can develop. It was certainly an important part of the old British system of training. We were well tutored in the art. This included learning how to feel for the shape, size, firmness and location of key organs and their spatial relationships to other organs.

And not only organs. There is great deal to be learned from any mass that might develop. Is it smooth or rough? Is it hard or soft? Does it move with breathing or is it fixed? Is there lymph node involvement? Does it pulsate? The answers to these questions can tell you a great deal about whether the mass is benign or malignant and, if the latter, how far it has progressed.

A FEW YEARS AGO, MY FORMER colleague Dr. David Naylor was invited to lecture to the American Osler Society — named, of course, for Sir William Osler, arguably the greatest physician of the modern age. His address provided a trenchant analysis of the two dominant streams of modern medicine. The first is quantitative, evidence-based practice, which, Naylor noted, “is dependent on applying averages and probabilities to individuals, based on inferences from clinical populations.” One might reasonably call this the Science stream.

The second, more patient-centric approach line of attack attempts to use all the skills and tools of medicine to determine the right diagnosis, prevention and treatment for a specific “biological profile” — in effect, the Art stream.

But regardless of which approach one uses, the hard reality, Naylor observed, is “that we remain at sea when it comes to understanding and preventing or treating many diseases.”

The physician should not treat the disease, but the patient who is suffering from it.

— Maimonides

IN THE LAST CHAPTER, I REVIEWED a series of cases dealing with the complex challenges that physicians face in dealing with syndromes that cannot be clearly identified, despite the obvious physical and mental suffering they inflict on patients. In this chapter, I will look at a few cases in which we can make a firm diagnosis of physical illness, but offer no effective or lasting solution. Here, the art of medicine is likely to be measured by other factors — by the level of care, attention, empathy and advocacy a doctor brings to the bedside. Sadly, in such situations, it is often necessary to deliver bad news to these patients. But that, too, is an art that needs to be developed.

A FEW YEARS AGO, A COLLEAGUE at a nearby hospital referred a very difficult case to me. Marnie was a 40-year-old woman that had been diagnosed with Erdheim-Chester disease. First identified by two pathologists in the 1930s — Austrian Jakob Erdheim and American William Chester — the syndrome is characterized by excessive production of histiocytes, a type of white blood cell that the body normally deploys to fight infection. When histiocytes over-produce, however, they invade the body’s connective tissue and begin to play havoc with key organs, including the heart, bone, kidneys and liver.

Discovery consists in seeing what everyone else has seen and thinking what no one else has thought.

— Albert von Szent-Györgyi, Nobel Prize–winning physiologist

IF PRACTISING THE ART OF MEDICINE is principally about bringing more humanity to the doctor-patient relationship, it is not only about humanity. Part of it involves devising creative approaches to diagnosis and treatment, or what I like to call out-of-the-box thinking.

I’m not sure how — or even whether — you can teach future generations of doctors to develop out-of-the-box thinking. The best analogy may be music. You usually need to have years of experience and exposure to the classic forms before you can begin to play jazz. Similarly, in medicine, I would argue that you need to have a broad and deep grasp of basic medicine before you can consider adopting more experimental tactics.

Regardless, it is certainly a skill that physicians young or seasoned would find useful. Quite frequently, disease does not present with the expected or familiar pattern. Especially in an age of multi-system medical problems, disease (and the treatment of it) is becoming a moving target, and physicians need to be agile enough to move with it. I can recall six or seven cases in particular that will help demonstrate what I mean.

The work of epidemiology is related to unanswered questions, but also to unquestioned answers.

— Dr. Patricia Butler

MEDICAL EDUCATION HAS CHANGED DRAMATICALLY during the last half century. In the vanguard of these changes was Canada’s McMaster University Medical School in Hamilton. Under the leadership of cardiologist John Evans, who became its founding dean, internal medicine specialist Bill Spaulding, respirologist E.J. Moran Campbell, and medical educators Howard Barrows and Geoff Norman, McMaster — beginning in 1965 — dramatically reshaped the curriculum, de-emphasizing the traditional approach to academic lectures and formal examinations.

Instead, it created a radically new model, based on self-­directed study, creative thinking and problem-based learning. The system proved so successful that universities all over the continent began to emulate it, including the prestigious Harvard Medical School, which called its own program New Pathway. They might well have added an asterisk to that title; it was new when McMaster pioneered the concept.

ONE OF THE MOST CHALLENGING aspects of a career in diagnostic internal medicine is the opportunity it inevitably presents to treat rare diseases. Typically, patients arrive in our offices after a primary health care physician and two or more specialists have done as much as they can and then, metaphorically, thrown up their hands and asked for diagnostic help.

Sometimes, the right answer turns out to have been hiding in plain sight. But just as often, the solution is difficult because it involves a rare, seldom-seen disease. Both the diagnostic process and the subsequent treatment are important aspects of the art of medicine.

Some years ago, I was invited to become consulting physician in internal medicine to a professional sports team in Toronto. The players needed attention from various specialists, including of course orthopedic surgeons, but they very seldom felt the need to seek my services. They were essentially too healthy. Then someone suggested it might be more useful if I consulted on members of the team’s executive management, so I agreed.